Annex A: Summary of One YearOperational Plan 2015/16
Royal Liverpool and Broadgreen Hospitals NHS Trust
Strategic context and directionTo include:
Outline of plan delivery in 2014/15 and narrative on the progress anticipated in 2015/16, within the context of the Trust’s previously submitted five year plan to 2018/19. To include the impact of strategic commissioning intentions, service changes, local health economy factors, competitive position, strategic developments, transactions and organisational sustainability. / 2014/15 Plan Delivery
Financial Performance
The Trust delivered its 2014/15 financial plan.
Operational Performance
With respect to national performance targets the Trust delivered well against each of these with the exception of: -
Emergency 4 hour waits
During 2014/15 112,690 patients were treated by the trust as emergency patients and 105,383 were treated within 4 hours. The trust did not achieve performance for March at 92.02%. The trust did not achieve quarter 4 (92.31%), and annual performance was below 95% at 93.52%. The purpose of this report is to analysis the reasons behind this performance and to agree the operational approach for 2015-16 including a performance trajectory which will be shared with the TDA and Monitor.
In common with the country RLBUHT has experienced significant pressure within the ED department. The graph below shows the 4 hour emergency access weekly performance (April to 28th March 2015)
Weekly performance
Reasons for breaches of the 4 hour standard
The predominant reason for breaching 4 hours is waiting for a bed, followed by ED review when the department is crowded with inpatients. The “Royal ED crisis” is two-fold, an increase in dependence of patients and the lack of egress for patients requiring beds.
The Trust continues to see more patients with increased acuity. The proportion of resus/majors has increased and is now averaging around 124 a day compared to 109 a day two years ago as shown in the first graph below. Similarly, as is shown in the second graph the number of patients over 75 attending the emergency department is also increasing.
The number of patients whose care could be met in an alternative setting continues to be high and shows an increasing trend over the last 12 months. This is the percentage of patients who are ready for discharge who are waiting community/ social services assessment or placement. This demonstrates the improvement of the internal processes. The trust is struggling to achieve the 4 hour standard because of increased acuity and flow is restricted as the wards are filling up with long stay patients due to a combination of high dependency and delays awaiting services/assessments.
The trust issued Liverpool CCG with a contract query on the 17th March due to the increase in ED attendances which, when taken with the increase in patients ready for discharge but unable to be discharged, is directly impacting upon the Trusts ability to deliver the 4 hour standard and is outside the trustscontrol to manage. The CCG initial response to this contract query is to be scrutinised at the contract meeting.
Healthcare Associated Infections
Clostridium Difficile
The trust has finished 2014/15 under trajectory with 43 cases against a target of 48.
In addition 5 cases have been removed via appeal processtaking the Trust total to 38.
MRSA Bacteraemia
The Trust has had 7 cases against a target of zero.On-going work on ANTT and peer review is complete.
There has been 1 case to date which we have requested third party arbitration
Other Achievements
New hospital – construction continues at a pace with Carillion working 24-7 on the lift cores in November and 7-day working on ground works through November and December, in an effort to regain time lost as a result of the original problems with asbestos.
Research and Development - we are making very strong progress with the Clinical Research Network and had a particularly successful launch event on 2nd December.
Foundation Trust application - continued development towards Foundation Trust status with Monitor having commenced final assessment in March 2015
Healthy Liverpool programme - this will lead to service transformation, greater collaborative working and potential organisational reconfiguration. Healthy Liverpool is targeting a reduction in the health inequalities and levels of deprivation in some parts of Liverpool compared to other parts and the rest of England. The Trust continues to work closely with commissioners and partner provider organisations to further the delivery of the programme.
The Trust is aligning itself with the key priority areas for 2015/16 set out by commissioners, in line with national planning guidance. Key areas of alignment include: -
- Local priority work programmes – discussions are underway to agree next steps in the Health Liverpool programme
- CQUIN – joint working by clinical leads to ensure that appropriate areas of added value are identified
- Benchmarking – identification of outlying arrangements
- Non-Elective Thresholds and Readmissions –establishment of baselines and penalty arrangements, both for local commissioning and specialised commissioning arrangements
Approach taken to improve quality and safety
To include:
The approach to quality improvement, the methodology used and the key improvements to be delivered over the next year across the five CQC domains of quality: safe, caring, effective, responsive and well-led. Consistent with information contained within the Trust’s published Quality Account. / The Trust has set its key corporate and quality objectives for 2015/16 which are illustrated below in the context of the overarching vision, values and strategic themes: -
Delivery of operational performance standards
Including contractual and national targets and standards. / The Trust plans to deliver all operational performance standards and is addressing issues where targets have not been achieved in 2014/15. It is developing measures that will allow targets to be achieved more sustainably, including through its transformation programme and re-alignment of its activities through establishment of business units with appropriate restructuring of operational management arrangements.
Actions planned to deliver key targets are outlined below.
Accident and Emergency
- Operational Plan for 2015-16
(*) Bed equivalent schemes
Scheme / Potential
Capacity / April / May / June / Sept / Dec / Jan
ED assessment area / 6 / 6 / 6 / 6 / 6 / 6 / 6
Frailty Unit* / 3 / 3 / 3 / 3 / 5 / 6 / 7
Palliative Care Unit / 12 / 0 / 0 / 12 / 12 / 12 / 12
Ward 4x (escalation) / 22 / 0 / 0 / -22 / -22 / -11 / 0
Critical Care Expansion / 2 / 0 / 0 / 0 / 2 / 2 / 2
Reduction in RfD- Hospital at Home / Best interest* / 6 / 3 / 3 / 6 / 6 / 6 / 6
Reduced LOS due to 7 day respiratory* / 6 / 0 / 0 / 0 / 6 / 6 / 6
Transfer LR to BGH / 8 / 0 / 0 / 8 / 8 / 8 / 8
Improved internal flow – 8:30 ward rounds, Toolkit embedding* / 6 / 6 / 6 / 6 / 8 / 8 / 8
Reduced LOS due to Internal Medicine Floor/GIM* / 12 / 0 / 0 / 0 / 6 / 12 / 12
Additional gains in the reduction of RfD patients* / 0 / 0 / 12 / 12 / 12 / 12
Day case beds / 6 / 6 / 6 / 6 / -6 / -6 / -6
Total / 24 / 24 / 31 / 43 / 61 / 79
Demand at current occupancy (98%) / 38 / 38 / 32 / 44 / 50 / 65
Gap / -14 / -14 / -1 / -1 / +11 / +14
This plan is based on averages and does not take into account the variation in discharges/admissions throughout the week and within the day with the Sun – Tuesday being the most challenging days and increased pressure.
ED Assessment Area- Additional investment has been made into ED to create a dedicated emergency triage area within the ground floor – “the Hub”. A new triage system “Pit-stop triage” was introduced in mid- March. These new clinical processes surrounding the hub require time to bed in and will be formally evaluated through staff engagement sessions at the end of April. The ED nursing vacancies have been filled with new recruits starting this week. The accommodation changes on the ground floor have released 6 additional beds.
Frailty Unit - This is a multi-agency service between RLBUHT, Liverpool City Council and Liverpool Community Trust. It has been operational Monday to Friday 9-5pm since December and from February the service extended over the 7 days. The additional LOS savings are from the extension of opening hours and bedding in of the unit.
Academic Palliative Care Unit - This is due to open in June/July and will create 12 additional beds on 4Y. This will also improve the discharge pathway for palliative patients which will bring additional LOS benefits, which have not been included at this stage.
Escalation Ward - 4x was opened in September initially as an elective ward, and then as the winter escalation ward. The intention is to close this in June to accommodate the medical examinations. This will be re-opened in December as part of the General Internal Medicine Floor.
Hospital at Home / Best Interest- There has been a reduction in the LOS of patients who are waiting for homecare packages, due to a winter scheme which the trust initially purchased via an independent homecare provider. Liverpool City Council is now providing this service in house. There has been an increase in the number of patients who require Best Interest (BI) to inform discharge decisions. The Trust has trained 30 members of staff last week to become BI assessors rather than rely on expertise from external agencies. This will reduce LOS for this category of patient.
Respiratory Medicine - 2 additional Consultant Respiratory Physicians have been appointed. This will enable the directorate to move to senior review of every inpatient every day, with a corresponding reduction in LOS.
Transfer of Limb reconstruction orthopaedic activity to BGH – A business case was approved last year for this service to move to BGH. The necessary estates work is being planned and staff recruited. This will also assist with the achievement of 18 weeks in orthopaedics.
General Internal Medicine (GIM) Floor – 7 day - This is a radically different way of managing short stay/general medical conditions, the development and implementation of this facility, 92 beds, is vital in supporting the delivery of a true seven day patient centric service. Implementation is being delivered through a multi-professional task force group with a number of key objectives, for example to:-
- ensure twice daily ward rounds happen consistently seven days a week for all patients
- improve patient outcomes for example, by providing speciality care at the point of need by timely onward referral
- reduce length of stay
Further gains from reducing the Ready For Discharge (RFD) list - the greatest capacity gain will be from this cohort of patients. The reasons for the delays fluctuate and are analysed with corrective schemes put in place.
Ideas currently being discussed with external colleagues include:
-Improving response times from community partners by up-skilling our own staff to undertake these assessments
-Improved response times from mental health services particularly at weekends
-Dedicated case manager for out of area complex cases – this is a small number of patients who disproportionally stay longer passed their
Day Case Beds- In extremity day case areas remain open for emergency patients. This is a last resort as this disrupts planned care, particularly in gastroenterology.
Gap
There are daily discussions to manage the capacity ‘gap’, which includes increase in outlying patients (medical patients in surgical wards); reduction if cancellation of elective cases. Ultimately, the 4 hour target remains compromised whilst there is a capacity gap. The consistent achievement of the target is more attainable when bed occupancy levels are less than 95%.
- Performance Trajectory 2015-16
- Key Risks
- Lack of confirmation of the resilience funds and contract offer which support a number of the schemes which are included in the operational plan.
- Unexpected changes to activity levels and case mix.
- Liverpool CCG expressing concerns regarding financial affordability.
- In ability to deliver elements due to availability of critical staff - medical workforce in ED and critical care nursing staff are of particular note
- Continued reduction in social care/ community support due to pressure on local authority budgets.
- Potential double counting of LOS efficiency from these plans and the transformation programme.
- Outcome of the contract query issued to Liverpool CCG.
- Lack of agreement with NHS England regarding Walk In Centre activity.
- Decline in NWAS turnaround times due to ED being overcrowded.
Current Performance
The Trust continues to achieve the incomplete 18 week RTT of 92%, but two specialties continue to underperform and are below trajectory, there are:-
- General Surgery (inc HPB & Colorectal)
- Trauma and Orthopaedics
General Surgery will achieve by the end of Quarter 1 and Trauma and Orthopaedics by the end of Quarter 2 – processes are in place to ensure Oral Surgery achievement is sustained.
Reasons for continued under delivery has been multifactorial and include:
- Complications of case mix and demand increases in some sub specialities.
- Recruitment difficulties for key personnel.
- Consultant long term sickness.
- Winter pressures
- Industrial Action
- Lack of single consistent waiting list management process.
- Capacity shortfall.
- Access Policy compliance
- Poor follow up processes
- Inconsistent validation processes
The improvements are classed into three categories:
- Governance and Monitoring
- Process and Information Flow
- Capacity
Outlined are the strong governance and escalation systems that underpin the effective management and delivery of 18 week RTT performance.
The 18 week RTT process and performance is discussed in three distinct structured meetings within the Trust:
Division of Surgery & Medicine Performance Meeting
This group provides assurance to the Director of Operations that the national access targets are being met. In addition the group will proactively identify potential capacity issues early in order for action to be taken.
The group also ensures that there are systematic processes underpinning the operations and management of the specialities.
18 Week RTT Pathway Meeting
Patients who are waiting > 18 weeks are discussed and actions taken. Diagnostic waiting times are tabled and any delayed waiting times within MCAS, which would impact upon T&O. This group provides the necessary assurance that processes for managing the 18 week RTT are resulting in improved performance.
18 Week Core Strategy Group Meeting
This group reviews all processes, policies procedures and documentation relating to 18 week RTT. This provides standardisation across all specialities.
In addition to the three structured meetings that all report to the Surgical Divisional Board, the Trust has either implemented or are in the process of:
Reviewing the data quality and implementing an annual audit.
We have had an external review of waiting list management.
The validation team has expanded, who are aligned to the performance meeting, who will then target areas identified as potential areas of concern.
Training package currently being developed, but will customised.
The introduction of a diagnostic PTL to ensure RTT pathways is aligned.
Access policy under review and being amended (this is in line with recommendations outlined with external review)
Mixed Sex Accommodation
The Trust had a few areas that continued to have difficulties with 100% compliance of mixed sex accommodation - this was in the main critical care areas. The action plan is attached.
Cancer Standards
In order to ensure that the Cancer Waiting Times targets are met the Trust has the following processes in place:
- All patients on an active pathway are tracked daily by the corresponding MDT Coordinator.
- There is a weekly PTL meeting for all tumour sites which are attended by the Cancer Manager, Cancer Data Manager, MDT Coordinator and corresponding Assistant Directorate Manager ensuring that any pathway issues are escalated during the meeting. Actions are sent out following the meeting and a response to escalation is expected within 24 hours. The Cancer Manager will escalate to the Directorate Manager and the Divisional General Managers if issues are not resolved.
- Escalations can also occur outside of the PTL meeting when necessary by the MDT Coordinators to the appropriate department via email. The Cancer Manager is always copied into escalation correspondence.
- Service specific issues are discussed weekly at the Surgical Performance Meeting and breach pathways are discussed here once a month to learn and act on emerging themes.
- Wherea specific service is experiencing delays the Risk Register is updated to reflect action plans and ensure that actions are reviewed and the problem is resolved.
- Advanced notice is given to all relevant departments regarding any National Campaigns to ensure that capacity is planned in advance for a surge in demand and services that experience a surge in demand at certain times of year (e.g. dermatology during the summer months) are required to provide a formal robust plan for capacity to the Cancer Core Team.
- The data held by the Trust on the Somerset Cancer Register is validated weekly by the relevant MDT Coordinators and also heavily scrutinised by the Cancer Manager and the Cancer Data Manager to ensure that all treatments are captured. A daily comparison with information held on Open Exeter also occurs in order to ensure that data is robust and accurate.